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...on Policy Issues
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www.ProjectCork.org
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Spring 2010
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The 10 most important things known about addiction.
Sellman D. Addiction 105(1): 6-13, 2010. (80 refs.)
If you were asked: 'What are the most important things we know about addiction?' what would you say? This paper brings together a body of knowledge across multiple domains and arranged as a list of 10 things known about addiction, as a response to such a question. The 10 things are: (1) addiction is fundamentally about compulsive behaviour; (2) compulsive drug seeking is initiated outside of consciousness; (3) addiction is about 50% heritable and complexity abounds; (4) most people with addictions who present for help have other psychiatric problems as well; (5) addiction is a chronic relapsing disorder in the majority of people who present for help; (6) different psychotherapies appear to produce similar treatment outcomes; (7) 'come back when you're motivated' is no longer an acceptable therapeutic response; (8) the more individualized and broad-based the treatment a person with addiction receives, the better the outcome; (9) epiphanies are hard to manufacture; and (10) change takes time. The paper concludes with a call for unity between warring factions in the field to use the knowledge already known more effectively for the betterment of tangata whaiora (patients) suffering from addictive disorders. Note: A number of commentaries in response to this article are published in the same issue. Copyright 2010, Society for the Study of Addiction to Alcohol and Other Drugs.
Benefit limits for behavioral health care in private health plans.
Hodgkin D; Horgan CM; Garnick DW; Merrick EL. Administration and Policy in Mental Health Services Research 36(1): 15-23, 2009. (36 refs.)
Data from a nationally representative sample of private health plans reveal that special lifetime limits on behavioral health care are rare (used by 16% of products). However, most plans have special annual limits on behavioral health utilization; for example, 90% limit outpatient mental health and 93% limit outpatient substance abuse treatment. As a result, enrollees in the average plan face substantial out-of-pocket costs for long-lasting treatment: a median of $2,710 for 50 mental health visits, or $2,400 for 50 substance abuse visits. Plans' access to new managed care tools has not led them to stop using benefit limits for cost containment purposes. Copyright 2009, Springer.
Can we prevent drug related deaths by training opioid users to recognise and manage overdoses?
Gaston RL; Best D; Manning V; Day E. Harm Reduction Journal 6(26), 2009. (30 refs.)
Background: Naloxone has been evidenced widely as a means of reducing mortality resulting from opiate overdose, yet its distribution to drug users remains limited. However, it is drug users who are most likely to be available to administer naloxone at the scene and who have been shown to be willing and motivated to deliver this intervention. The current study builds on a national training evaluation in England by assessing 6-month outcome data collected primarily in one of the participating centres. Methods: Seventy patients with opioid dependence syndrome were trained in the recognition and management of overdoses in Birmingham (n = 66) and London (n = 4), and followed up six months after receiving naloxone. After successful completion of the training, participants received a supply of 400 micrograms of naloxone (in the form of a preloaded syringe) to take home. The study focused on whether participating users still had their naloxone, whether they retained the information, whether they had witnessed an overdose and whether they had naloxone available and were still willing to use it in the event of overdose. Results & Discussion: The results were mixed - although the majority of drug users had retained the naloxone prescribed to them, and retention of knowledge was very strong in relation to overdose recognition and intervention, most participants did not carry the naloxone with them consistently and consequently it was generally not available if they witnessed an overdose. The paper discusses the reasons for the reluctance to carry naloxone and potential opportunities for how this might be overcome. Future issues around training and support around peer dissemination are also addressed. Conclusion: Our findings confirm that training of drug users constitutes a valuable resource in the management of opiate overdoses and growth of peer interventions that may not otherwise be recognised or addressed. Obstacles have been identified at individual (transportability, stigma) and at a systems level (police involvement, prescription laws). Training individuals does not seem to be sufficient for these programmes to succeed and a coherent implementation model is necessary. Copyright 2009, BioMed Central.
Measuring attractiveness for abuse of prescription opioids.
Butler SF; Fernandez KC; Chang A; Benoit C; Morey LC; Black R et al. Pain Medicine 11(1): 67-80, 2010. (26 refs.)
Objective. Prescription opioids are the second most misused/abused drug in the United States behind only marijuana. Recreational prescription opioid users appear to prefer some products over others; however, the extent to which attributes of any particular formulation account for such preferences has yet to be determined. The Opioid Attractiveness Technology Scaling was developed to identify the particular features of a prescription opioid that are relevant to its attractiveness for recreational use, and to use these features to model attractiveness for recreational use of particular prescription opioid formulations. Design. Four hundred and ninety-one self-reported recreational prescription opioid users identified 43 product features as being relevant to determining whether a product is "attractive" or "unattractive" for recreational use. Average ratings were used to determine appropriate weights to be applied to the features. A factor analysis yielded 10, highly differentiated factors. Five hundred and sixty-four prescription opioid abusers were then asked to rate the extent to which the 43 features identified in Study 1 were relevant to specific prescription opioid products they had used. Results. Respondents provided an overall preference rating of these products and a model was created. A random intercept model yielded a significant pseudo R-2 of 0.14 (chi-square = 310.02, degrees of freedom [df] = 10, P < 0.001). The model fit least well, albeit significantly, for abusers who preferred to swallow the drug (pseudo R-2 = 0.06; chi-square = 55.52, df = 10, P < 0.001) and best for those who preferred to inject (pseudo R-2 = 0.37; chi-square = 199.34, df = 10, P < 0.001). Conclusions. The relevance of the model is discussed along with possible modifications that might allow prediction of "attractiveness" of "abuse deterrent" formulations that have not yet been marketed. Copyright 2010, Wiley-Blackwell Publishing.
Vested interests in addiction research and policy. Alcohol policies out of context: Drinks industry supplanting government role in alcohol policies in sub-Saharan Africa.
Bakke O; Endal D. Addiction 105(1): 22-28, 2010. (31 refs.)
Background: In this paper, we describe an analysis of alcohol policy initiatives sponsored by alcohol producer SABMiller and the International Center on Alcohol Policies, an alcohol industry-funded organization. In a number of sub-Saharan countries these bodies have promoted a 'partnership' role with governments to design national alcohol policies. Methodology: A comparison was conducted of four draft National Alcohol Policy documents from Lesotho, Malawi, Uganda and Botswana using case study methods. Findings: The comparison indicated that the four drafts are almost identical in wording and structure and that they are likely to originate from the same source. Conclusions: The processes and the draft policy documents reviewed provide insights into the methods, as well as the strategic and political objectives of the multi-national drinks industry. This initiative reflects the industry's preferred version of a national alcohol policy. The industry policy vision ignores, or chooses selectively from, the international evidence base on alcohol prevention developed by independent alcohol researchers and disregards or minimizes a public health approach to alcohol problems. The policies reviewed maintain a narrow focus on the economic benefits from the trade in alcohol. In terms of alcohol problems (and their remediation) the documents focus upon individual drinkers, ignoring effective environmental interventions. The proposed policies serve the industry's interests at the expense of public health by attempting to enshrine 'active participation of all levels of the beverage alcohol industry as a key partner in the policy formulation and implementation process'. Copyright 2010, Society for the Study of Addiction to Alcohol and Other Drugs.
Impact of brewery effluent on water quality of the Olosun river in Ibadan, Nigeria.
Ipeaiyeda AR; Onianwa PC. Chemistry and Ecology 25(3): 189-204, 2009. (49 refs.)
There has been significant pollution of the Olosun river in Ibadan with untreated brewery effluent. The nature and extent of pollution resulting from effluent discharged into this river has not been fully investigated. This study investigated the impact of such effluents on the water quality of the Olosun river. Sampling points of river water included two upstream locations up to 100 m from the discharge point, the effluent discharge point and six points downstream. The Olosun river was sampled up to about 690 m downstream. Sampling of river water was carried out on a monthly basis between March 2001 to March 2002 and January 2004 to December 2004. The physico-chemical impact on the water quality downstream was indicated by reduced pH and dissolved oxygen. The levels of chloride, nitrate, ammonia, dissolved solids, turbidity and BOD were significantly high, arising from the inflow of brewery effluent. The brewery effluent significantly contributed to the levels of Ni, Zn, Cr, Co, Cu, Cd and Pb downstream such that they exceeded the freshwater and drinking water criteria. In addition, the overall concentrations of these heavy metals were well above the background concentration obtained at the upstream location. The levels of these indicator parameters responsible for this brewery effluent quality exceeded the effluent guideline for discharge into surface water. Thus, brewery effluent is among the major sources or factors responsible for river water quality deterioration. Copyright 2009, Taylor & Francis.
Prescription drug abuse and methods of diversion: The potential role of a pharmacy network.
El-Aneed A; Alaghehbandan R; Gladney N; Collins K; Macdonald D; Fischer B. Journal of Substance Use 14(2): 75-83, 2009. (46 refs.)
Prescription drug abuse is a growing problem in North America. Evidence indicates that prescription drugs have replaced traditional 'street' drugs in major metropolitan Canadian sites. Drug abusers tend to use multiple drugs at the same time, escalating the associated risks and increasing the complexity of the issues surrounding drug abuse. To address this problem, interventions at varying levels are needed, one of which includes the support of electronic health records initiatives, such as a pharmacy network. This network will enable health care providers to access patients' comprehensive drug history at the point of care and physicians will be able to e-prescribe medications. Such functionalities can theoretically limit the degree of drug diversion towards the illegal market. Common practices among drug abusers/diverters can be reduced and monitored, such as visiting multiple physicians and pharmacies, prescription forgery, illegal prescribing, and diverting methadone that is used to treat opioid dependence. This discussion paper will introduce the issue of prescription drug abuse within the Canadian context and discuss drug diversion methods. Discussion will focus on to the possible role of a pharmacy network in limiting major diversion methods and supporting the medical system assisting those who suffer from drug abuse problems. Copyright 2009, Informa Healthcare.
The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms. (review).
Elder RW; Lawrence B; Ferguson A; Naimi TS; Brewer RD; Chattopadhyay SK et al. American Journal of Preventive Medicine 38(2): 217-229, 2010. (110 refs.)
A systematic review of the literature to assess the effectiveness of alcohol tax policy Interventions for reducing excessive alcohol consumption and related harms was conducted for the Guide to Community Preventive Services (Community Guide) Seventy-two papers or technical reports, which were published prior to July 2005, met specified quality criteria, and included evaluation outcomes relevant to Public health (e.g, binge drinking, alcohol-related crash fatalities), were Included in the final review. Nearly all studies, including those with different Study designs, found that there was all inverse relationship between the tax or price of alcohol and indices of excessive drinking or alcohol-related health outcomes Among Studies restricted to underage populations, most found that increased taxes were also significantly associated with reduced consumption and alcohol-related harms. According to Community Guide rules of evidence, these results constitute strong evidence that raising alcohol excise taxes is all effective strategy for reducing excessive alcohol consumption and related harms. The impact of a potential tax increase is expected to be proportional to its magnitude and to be modified by such factors as disposable income and the demand elasticity for alcohol among various population groups. Copyright 2010, Elsevier Science.
NAOMI: The trials and tribulations of implementing a heroin assisted treatment study in North America.
Gartry CC; Oviedo-Joekes E; Laliberte N; Schechter MT. Harm Reduction Journal 6(2), 2009. (61 refs.)
Background: Opioid addiction is a chronic, relapsing disease and remains a major public health challenge. Despite important expansions of access to conventional treatments, there are still significant proportions of affected individuals who remain outside the reach of the current treatment system and who contribute disproportionately to health care and criminal justice costs as well as to public disorder associated with drug addiction. The NAOMI study is a Phase III randomized clinical trial comparing injectable heroin maintenance to oral methadone. The study has ethics board approval at its Montreal and Vancouver sites, as well as from the University of Toronto, the New York Academy of Medicine and Johns Hopkins University. The main objective of the NAOMI Study is to determine whether the closely supervised provision of injectable, pharmaceutical-grade opioid agonist is more effective than methadone alone in recruiting, retaining, and benefiting chronic, opioid-dependent, injection drug users who are resistant to current standard treatment options. Methods: The case study submitted chronicles the challenges of getting a heroin assisted treatment trial up and running in North America. It describes: a brief background on opioid addiction; current standard therapies for opioid addiction; why there is/was a need for a heroin assisted treatment trial; a description of heroin assisted treatment; the beginnings of creating the NAOMI study in North America; what is the NAOMI study; the science and politics of the NAOMI study; getting NAOMI started in Canada; various requirements and restrictions in getting the study up and running; recruitment into the study; working with the media; a status report on the study; and a brief conclusion from the authors' perspectives. Results and conclusion: As this is a case study, there are no specific results or main findings listed. The case study focuses on: the background of the study; what it took to get the study started in Canada; the unique requirements and conditions of getting a site, and the study, approved; working with the media; recruitment into the study; a brief status report on the study; and a brief conclusion from the authors' perspectives. Copyright 2009, BioMed Central.
Worksite-based incentives and competitions to reduce tobacco use: A systematic review. (review).
Leeks KD; Hopkins DP; Soler RE; Aten A; Chattopadhyay SK. American Journal of Preventive Medicine 38(2, Supplement 2): S263-S274, 2010. (55 refs.)
The Guide to Community Preventive Service (Community Guide) methods for systematic reviews were used to evaluate the evidence of effectiveness of worksite-based incentives and competitions to reduce tobacco use among workers. These interventions offer a reward to individuals or to teams of individuals on the basis of participation or success in a specified smoking behavior change (such as abstaining from tobacco use for a period of time). The review team identified a total of 26 published studies, 14 of which met study design and quality of execution criteria for inclusion in the final assessment. Only one study, which did not qualify for review, evaluated the use of incentives when implemented alone. All of the 14 qualifying studies evaluated incentives and competitions when implemented in combination with a variety of additional interventions, such as client education, smoking cessation groups, and telephone cessation support. Of the qualifying studies, 13 evaluated differences in tobacco-use cessation among intervention participants, with a median follow-up period of 12 months. The median change in self-reported tobacco-use cessation was an increase of 4.4 percentage points (a median relative percentage improvement of 67%). The present evidence is insufficient to determine the effectiveness of incentives or competitions, when implemented alone, to reduce tobacco use. However, the qualifying studies provide strong evidence, according to Community Guide rules, that worksite-based incentives and competitions in combination with additional interventions are effective in increasing the number of workers who quit using tobacco. In addition, these multicomponent interventions have the potential to generate positive economic returns over investment when the averted costs of tobacco-associated illnesses are considered. A concurrent systematic review identified four studies with economic evidence. Two of these studies provided evidence of net cost savings to employers when program costs are adjusted for averted healthcare expenses and productivity losses, based on referenced secondary estimates. Copyright 2010, Elsevier Science.
Methamphetamine and driving.
Lemos NP. Science & Justice 49(4): 247-249, 2009. (11 refs.)
Methamphetamine incidence in driving under the influence cases in the City and County of San Francisco is a significant and on-going challenge. Two methamphetamine positive driving cases are presented herein demonstrating some similarities in observed signs and symptoms and drug blood concentrations but which are also characterized by very different driving styles and behaviours towards the police officers when encountered on the road. Copyright 2009, Forensic Science Society.
Drugs policy: What should we do about cannabis?
Pudney S. Economic Policy 61: 165-211, 2010. (69 refs.)
Public policy has failed to prevent large-scale consumption of cannabis in most developed countries. So what, if anything, should we do to change the policy environment? Cannabis consumption is unambiguously harmful in several ways, but this does not automatically justify the prohibitionist policy dictated by the international drugs conventions. This paper sets out the arguments for policy intervention in
the cannabis market and reviews the directions of policy change that have been called for. We argue that existing theoretical insights and empirical evidence give little compelling reason to prefer prohibition to the alternative of legalization of cannabis with harms controlled by regulation and taxation. Given this conclusion and the much wider prevalence of cannabis than of harder drugs, a reasonable way forward is to remove cannabis production and consumption (but not trade) from the current prohibitionist UN drug control treaties, to allow countries to adopt their own policies, thus generating new evidence on the potential impacts of a wider range of policy. Copyright 2010, Wiley-Blackwell Publishing.
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